What Is Unbundling in Medical Billing?

1
What Is Unbundling in Medical Billing?
2

• The importance of medical billing isnt something
  that we need to restate, but it is something that
  can be particularly challenging for small medical
  offices in particular. One of the main issues
  that healthcare providers, big or small, tend to
  have with medical billing is something known as
  unbundling this is a practice that can lead to
  things
• Financial losses
• Incorrect claims
• Even legal trouble
• Lets explore what unbundling in medical
  billing is in a bit more detail, including why
  this sort of thing happens and how youre able to
  shield yourself from potential pitfalls

3
Understanding Unbundling in Medical Billing

• In essence, unbundling is something that occurs
  when a healthcare provider or billing department
  submits separate claims for medical services
  youve provided that should actually all be
  grouped together under a single CPT code.
• As you may be aware, CPT (Current Procedural
  Terminology) codes are what we use to describe
  all the medical services and procedures our
  patients receive from us, so theres a CPT coding
  system to go along with this thats meant to
  simplify billing while still ensuring that your
  practice is getting compensated properly for your
  work.

4

• Every one of these CPT codes represents a
  specific medical service or procedure whether
  its performing surgery or prescribing medication
  and these are the codes you then send to the
  insurance companies and payers in order to
  actually process medical bills.
• Having said that, in some cases, you might
  accidentally separate CPT codes to describe parts
  of a procedure youve done that were meant to be
  grouped under one code this is what we call
  unbundling. The end result? Inflated charges for
  the same patient and incorrect reimbursement for
  your practice.

5
Why Does Unbundling Happen?

• Unbundling can generally occur for a handful of
  different reasons, so no one will immediately
  assume that you had malicious intent if this
  happens to you.
• In the majority of cases, unbundling is basically
  just the result of medical coding errors, whether
  your practices billing team doesnt know how to
  code the correct way for certain services or if
  they simply lack an understanding of the National
  Correct Coding Initiative (NCCI) guidelines.

6

• In fact, the NCCI was actually made with the aim
  of promoting proper coding practices in order to
  reduce errors like unbundling, but without the
  proper training (which can be pretty
  time-consuming if youre running a small practice
  and have all your physicians are occupied with
  other things), it can still end up being
  difficult for your billing team to stay
  compliant.
• Unfortunately, though, theres still the chance
  that a healthcare provider is intentionally
  unbundling in an attempt to increase
  reimbursement for medical services theyve
  provided billing for individual parts of a
  surgical procedure rather than using the
  appropriate bundled procedure code (which would

7

• end up leading to higher payouts), for
  example.
• It goes without saying that this is a pretty
  unethical practice, but most importantly, its
  completely illegal and could result in severe
  penalties.
• Impact of Unbundling on Medical Practices
• If one of your claims is identified as unbundled,
  theres a fairly strong chance that itll be
  denied by insurance companies not only delaying
  payments but also hurting your cash flow, which
  can obviously be pretty catastrophic if youre a
  small

8

• thing, but if youve repeatedly been caught
  unbundling, it can result in the following
• Audits
• Fines
• Possible legal action
• Damage to your practices reputation and
  financial standing
• Of course, honest mistakes can happen, but its
  entirely your responsibility for the accuracy of
  your own medical billing, so just ensure that
  youre using the correct CPT code each time if
  you want to avoid any kinds of compliance issues.

9
How to Avoid Unbundling

• Naturally, youre going to need to have a fairly
  thorough understanding of the CPT coding system
  and the NCCI guidelines in order to avoid
  unbundling, so there are a few things you can do
  to give yourself a fighting chance
•   Training your billing staff regularly
•   Conducting regular audits of your billing
  practices
•   Reviewing medical records to spot any
  potential issues before they escalate.

10
Consider Partnering with PMN

• Tools like EHR systems can be useful when
  checking for bundled codes, as they notify you if
  separate claims for a bundled service are
  submitted. That said, technology alone is
  definitely not enough here, so its paramount
  that you combine technology with human expertise
  so you can properly ensure your coding is not
  only accurate but fully compliant with guidelines
  like the NCCI.
• This is an area where partnering with a leading
  medical billing company like PMN can be a huge
  relief for your practice! Our medical billing
  experts have been handling the billing processes
  of small practices in California for

11

• 20 years, so were well-equipped when it
  comes to eliminating medical coding errors like
  unbundling.
• Furthermore, our team is trained to correctly
  apply CPT codes for every procedure your practice
  makes even for more complex cases involving
  multiple medical services provided to the same
  patient not to mention that were also on the
  lookout for any changes in the CPT coding system.
  As such, youre not only getting accurate claims
  but can avoid costly denials and delays, too.
• Ultimately, were here to take all the
  administrative burden of billing off your
  shoulders so that you and the limited number of
  physicians you have can get back to treating your
  patients directly.

12

• If youd like to hear more about the range of
  services we can provide your practice from
  managing medical bills to ensuring compliance
  with coding rules make sure you contact our
  team today by giving us a call at [phone].
  Alternatively, feel free to book an appointment
  if youd prefer an in-person chat at our office
  in Laguna Hills, Orange County, California.